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Foods coverage, be aware that you and your dependents will be able to get this coverage
back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with All American Quality Foods and
don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay
a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month
that you did not have that coverage. For example, if you go nineteen months without creditable coverage,
your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You
may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug
coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug
Coverage…
Contact the person listed below for further information call Donna Butler at (770) 474-5904.
NOTE:
You’ll
get this notice each year. You will also get it before the next period you can join a Medicare drug plan,
and if this coverage through All American Quality Foods changes. You also may request a copy of this
notice at any time. MODEL INDIVIDUAL
CREDITABLE
COVERAGE DISCLOSURE NOTICE
LANGUAGE OMB 0938-0990 FOR USE ON OR AFTER APRIL 1, 2011
CMS Form 10182-CC Updated April 1,
2011
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this
information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
3
For More Information About Your Options Under Medicare Prescription
Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare
& You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also
be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is
available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one
of the Medicare drug plans, you may be required to provide a copy of this
notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to pay
a higher premium (a penalty).
NOTICE LANGUAGE
OMB 0938-0990
FOR USE ON OR AFTER APRIL 1, 2011
CMS
Contact--Position/Office: Donna Butler
Address: 125 Eagles Landing Parkway, Stockbridge, Ga 30281
Phone Number: (770) 474-5904
For More Information About Your Options Under Medicare Prescription
Drug Cov rage…
More detailed information about M dicare plans that offer prescription drug coverage is in the “Medicare
& You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also
be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income a d re ources, extra help paying for Medicare prescription drug coverage is
available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one
of the Medicare drug plans, you may be required to provide a copy of this
notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to pay
a higher premium (a penalty).
NOTICE LANGUAGE
OMB 0938-0990
FOR USE ON OR AFTER APRIL 1, 2011
CMS
Contact--Position/Office: Donna Butler
Address: 125 Eagles Landing Parkway, Stockbridge, Ga 30281
Phone Number: (770) 474-5904